Memories of a medication error

A recent study published in the Journal of Nursing Care Quality looks at medication errors from the perspective of nurses.  While the researchers sought information about reporting of errors, importance of technology in reducing errors, and current medication administration procedures, they also asked open-ended questions allowing nurses to share their own experiences with medication errors.

"Nurses were asked, "How did you feel when you made a medication error?" This question yielded somewhat surprising results. Many of the medication error incidents had occurred years before completion of the survey yet responses retained the emotions associated with it. Themes that emerged from these comments included concerns about patient harm; violation of trust; culpability, shame, and self-blame; loss of self-esteem and professional self-image; and an awareness that the system had failed them."

When I was a senior nursing student, I neglected to check a patient’s heart rate before giving him a dose of digoxin. I was devastated. As soon as I saw him swallow the pill, it hit me that I hadn’t taken his pulse. I panicked and grabbed his wrist. His pulse was 62; above the “Hold for heart rate less than 60” but not by much. I hadn’t thought about this incident for a long time, but now thinking back, I can remember this clinical day so vividly. My first concern, of course, was for the well-being of the patient and fortunately, his vital signs remained stable. My own feelings of self-doubt and failure, however, stayed with me for quite some time. How could I have forgotten something so important and yet so simple? 

Read the full text of When the 5 Rights Go Wrong: Medication Errors from the Nursing Perspective while it’s on our Recommended Reading list. Please share your own experiences and feelings by leaving a comment!

Posted: 6/7/2010 9:00:43 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

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